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The maximium period of time that can be entered on a single DOH-4471 form is 90 days. This can be a combination of retroactive current and prospective coverage. PAGE 1 Please read the definition of an emergency medical condition on page one of the DOH-4471 form. Fill in the spaces for the patient s name Client Identification Number CIN date of birth address city state and zip code. Only the treating physician may sign the physician s certificatio.

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